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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />--)0 If <br />SERVICE REQUEST # <br />OWNER! OPERATOR <br />—7-n 5 3 4 ,‹ / /14 (-) All 4 Al M /7 CHECK if BILLING ADDRESS <br />FACILITY NAME /--/(.-/-5 All'I'f <br />SITE ADDRESS • 1 i ezii„_ /1 / Street Number Direction Street Name <br />_cite v"--.74e/4-1-o <br />City <br />9 5 g /1 <br />Zip Code <br />HOME Or WALING ADDRESS (If Different from Site Address) <br />t-', iii A ,'1'4 6/es cu< Street Number C /4 Street Name <br />CITY S . VA- ii^, C • 4 74-c STATE 5.- C Al ZIP ," 5 8 3 <br />EXT. PHONE #1 <br />(g /1') a 0 7 Q °7 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />M 4s ro A P'-v 71- i c 6 CHECK if BILLING ADDRESS a <br />BUSINESS NAME / .-- 8 7 3 _..C6- .6 -6 PHONE # EXT. <br />HOME or MAILING ADDRESS 30 /9/ r% ,-et. (les" (//(2 FAX # <br />( ) <br />CITY 5.1c. y-- ... wts ,r71.-r, STATE (--, A zip 95g3c <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER Er OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />PAYMENT <br />TYPE OF SERVICE REQUESTED: Vfk \,1 \,1 I(. c I RECEIVED r 7 L1 ) i (- )(C— 6/ ii I <br />COMMENTS: <br />LI C., cs 67 D-- IP ---7-7 -') <br />MAR 0 8 2017 <br />1 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:c,If2(-\\ t -Ck EMPLOYEE #: DATE: - co>. ) 7 <br />ASSIGNED TO: U3-7)11 0 EMPLOYEE #: DATE: ...3- (:"6._ ) --) <br />Date Service Completed(if already completed): SERVICE CODE: 0 i4. 1 P/E: i &)63 <br />Fee Amount: v ?...)ci -- Amount Paid i 3c7 • c--- Payment Date -... cg — / 7 <br />Payment Type • ,-_, Invoice # <br />F.tnit- 1 1 cg 0 --rm Received By: <br />Title <br />my representative. <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)